Compositions and methods for the treatment of cystic fibrosis

ABSTRACT

The invention is directed to novel pharmaceutical compositions comprising chemicals agents that are useful in the treatment and prevention of cystic fibrosis and the prevention of signs and symptoms of this disease. These pharmaceutical compositions are surprisingly successful in the treatment disorders related to cystic fibrosis including disorders of blood production. Many of these compositions of the invention are even more effective when administered to a patient in pulses. Pulse therapy is not a form of discontinuous administration of the same amount of a composition over time, but comprises administration of the same dose of the composition at a reduced frequency or administration of reduced doses.

FIELD OF THE INVENTION

The invention relates to pharmaceutically acceptable compositions foradministration to humans to treat cystic fibrosis and also to methodsfor effectively utilizing these compositions.

BACKGROUND OF THE INVENTION

Cystic fibrosis (CF) is a systemic disorder that results when mutationsin the cystic fibrosis transmembrane conductance regulator (CFTR), anapical membrane glycoprotein, lead to a reduction in apical membranechloride transport. CFTR is a cAMP-dependent chloride channel thatregulates fluid composition in the respiratory and gastrointestinaltracts. CF is a heritable disease that follows an autosomal recessivepattern of transmission. It is the most common invariably lethal geneticdisease in the United States, with frequency among Caucasians being onein two thousand. One in twenty are carriers of the defective gene. CF ischaracterized by abnormal endocrine and exocrine gland function. In CF,unusually thick mucus leads chronic pulmonary disease and respiratoryinfections, insufficient pancreatic and digestive function, andabnormally concentrated sweat. Seventy percent of the mutant CFTRalleles in the Caucasian population result from deletion ofphenylalanine at position 508 (AF508-CFTR), the result of a three basepair deletion in the genetic code. Other mutations have also beendescribed and many may exist. The ΔF508-CFTR mutation results in a CFTRprotein capable of conducting chloride, but absent from the plasmamembrane because of aberrant intracellular processing. Under usualconditions (37° C.), the ΔF508-CFTR protein is retained in theendoplasmic reticulum (ER), by prolonged association with the ERchaperones, including calnexin and hsp70. The retained CFTR protein isthen targeted for degradation by the ubiquitin proteasome pathway. Overexpression of ΔF508-CFTR can result in ΔF508-CFTR protein appearing atthe cell surface, and this protein is functional once it reaches thecell surface. The ΔF508 “trafficking” block is also reversible byincubation of cultured CF epithelial cells at reduced temperatures(25-27° C.). Lowered temperature results in the appearance of CFTRprotein and channel activity at the cell surface, suggesting anintrinsic thermodynamic instability in ΔF508-CFTR at 37° C. that leadsto recognition of the mutant protein by the ER quality controlmechanism, prevents further trafficking, and results in proteindegradation. High concentrations of glycerol (1 M or 10%), a proteinstabilizing agent or chemical chaperone, also appears to facilitatemovement of ΔF508-CFTR from the ER to the plasma membrane.

Some of the palliative treatments involve the administration ofbiologically active proteins or chemical compounds to decrease theviscosity of secretions, or to suppress chronic infections of theairways. These treatments have a number of limitations, and do notaddress the illness directly, but rather attempt to treat the symptoms.Some require continuous use at fairly high doses while others have shorteffective half-lives. Tolerance to the active ingredient often developsrendering the composition functionally useless. In addition to problemsassociated with tolerance, the substances themselves or their metabolicby-products or carriers can quickly reach toxic levels in the patient'ssystem which impair kidney or liver function. Further, the chemicalcompounds themselves can be rapidly destroyed by catabolic enzymes,found in the cells and serum such as aminases, oxidases and hydrolases.Many of these enzymes are also found in hepatic cells, the principalsites for cleansing of the blood. Those able to survive cellular andhepatic catabolic processes are quickly eliminated from the patient'ssystem by the kidneys. Consequently, in vivo retention times for activecompounds are extremely short and the ability to achieve any sort ofsustained biological effect becomes nearly impossible or, at least,impractical.

Gene therapy for cystic fibrosis has been attempted, but has not beensuccessful to date for a number of reasons, including problems withdelivery of the gene to airway cells, insufficient levels of geneexpression, inadequate duration of gene expression, and toxicity of thegene therapy preparations.

A recent publication used 4-phenylbutyrate (4PBA) to enable a greaterfraction of ΔF508-CFTR to escape degradation and appear at the cellsurface (Rubenstein, R. C., Egan, M. E., and Zeitlin, P. L. In vitropharmacologic restoration of CFTR-mediated chloride transport withsodium 4-phenyl butyrate in cystic fibrosis epithelial cells containingdelta-F508-CFTR. J. Clin. Invest. 100:2457-65, 1997). Briefly, primarycultures of nasal polyp epithelia from CF patients (ΔF508 homozygous orheterozygous), or the CF bronchial epithelial cell line IB3-1(ΔF508/W1282X) were exposed to 4PBA for up to 7 days in culture. 4PBAtreatment at concentrations of 0.1 and 2 mM resulted in the restorationof forskolin-activated chloride secretion. Protein kinase A-activated,linear, 10 pS chloride channels appeared at the plasma membrane of IB3-1cells at the tested concentration of 2.5 mM 4PBA. Treatment of IB3-1cells with 0.1-1 mM 4PBA and primary nasal epithelia with 5 mM 4PBA alsoresulted in the appearance of higher molecular mass forms of CFTR,consistent with addition and modification of oligosaccharides in theGolgi apparatus, as detected by immunoblotting of whole cell lysateswith anti-CFTR antisera. Immunocytochemistry in CF epithelial cellstreated with 4PBA was consistent with increasing amounts of ΔF508-CFTR.

As 4PBA is an analogue of butyrate, a known transcriptional regulator ofCFTR expression (Cheng, S. H., Fang, S. L., Zabner, J., Marshall, J.,Piraino, S., Schiavi, S. C., Jefferson, D. M., Welsh, M. J., and Smith,A. E. Functional activation of the cystic fibrosis trafficking mutantΔF508-CFTR by expression. Am. J. Physiol. 268:L615-24, 1995), it washypothesized that 4PBA might increase transcription of the ΔF508-CFTRallele (Rubenstein et al.). If it were a transcriptional regulator, 4PBAmight thereby increase levels of ΔF508-CFTR protein, and by mass action,would force some ΔF508-CFTR to bypass quality control in the ER. Such amechanism would be consistent with the observations that butyrate itselfcan induce cAMP-responsive chloride secretion in a ΔF508-homozygouspancreatic acinar cell line (Cheng et al.). The results observed wereconsistent with 4PBA increasing the amount of ΔF508-CFTR proteinproduced, but their data demonstrated that this was not due to atranscriptional regulatory effect of 4PBA on the CFTR gene. Inimmunoblot experiments, increased CFTR immunoreactivity was observed inthe 4PBA-treated samples. Increased CFTR immunoreactivity was alsoobserved by immunocytochemistry after 4PBA treatment, but no changes inCFTF RNA levels were found with 4PBA treatment. The authors furtherstated that butyrate and 4PBA have effects in IB3-1 cells that arequalitatively different from one another. Respiratory epithelial cellstreated with 1-2 mM 4PBA are healthy, grow at a similar rate and with asimilar morphology to control cells, and express CFTR channel activityat the plasma membrane. Equimolar concentrations of butyrate causedmorphologic changes in IB3-1 cells, with rounding of cells and decreasedgrowth rate.

This seems to indicate that 4PBA and butyrate may have differenttoxicity profiles and dose-response relationships. In addition, otherpublished observations with butyrate in ΔF508-CFTR transfected C-127cells found that the ˜180-kD mature glycosylated species of CFTR was notobserved after 5 mM butyrate treatment for 24 hours, despite a massiveincrease in ΔF508-CFTR mRNA as demonstrated by Northern analysis (Chenget al.). This data thus did not demonstrate any effects of butyrate onCFTR protein levels or function, only changes in cellular morphology andcell death (Rubenstein et al.). Rubenstein et al observed no increasesin CFTR mRNA in response to 4PBA and indicated that the mechanism ofaction of 4PBA was not similar to that of butyrate or related toincreasing ΔF508-CFTR transcription. In addition, no increases incAMP-stimulation was observed which would be indicative of chloride iontransport even after treatment with up to 300 mM butyrate (Cheng etal.).

These data argue against any beneficial or therapeutic effect ofbutyrate on cystic fibrosis. In fact, some authors even stated thatbutyrate is likely too toxic to use clinically (Rubenstein et al.).Further, the authors made a strong case that 4PBA, which was indicatedto be possibly clinically useful, works though a mechanism, whichalthough unknown, is different from butyrate. Taken together, the use ofbutyrate, and the newer butyrate-derived compounds claimed, as CFtherapeutics is contra-indicated according to these reports. Moreover,4PBA has been used in a few CF patients clinically, but was not welltolerated due to large number of pills required (i.e. very shorthalf-life), and other side effects and, in consideration, that study wasterminated.

DESCRIPTION OF THE INVENTION

As embodied and broadly described herein, the present invention isdirected to novel chemicals and novel pharmaceutical compositionscomprising these and other chemicals that can be used in the treatmentand prevention of diseases and disorders associated with cysticfibrosis. The invention is further directed to methods for theadministration of these pharmaceutical compositions to patients for thetreatment of cystic fibrosis and prevention of its signs and symptoms.

It has been discovered that a group of chemicals and pharmaceuticalcompositions containing one or more such chemicals are surprisinglysuccessful in the treatment of cystic fibrosis and other disordersincluding, for example, disorders of blood production. Alsosurprisingly, it was discovered that many of these compositions are evenmore effective when administered to a patient in pulses. Pulse therapyis not a form of discontinuous administration of the same amount of acomposition over time, but comprises administration of the same dose ofthe composition at a reduced frequency or administration of reduceddoses.

According to these methods, cystic fibrosis and other disorders can beeffectively treated and without unnecessary adverse side effects to thepatient. Although most compositions are generally safe and non-toxic attherapeutic doses, pulsed administration further reduces risksassociated with, for example, toxicity, allergic reactions, the build-upof toxic metabolites and inconveniences associated with conventionaltreatment. In addition, these chemical compositions, now useful at asubstantially reduced dose and frequency, have a significantly reducedrisk of complications such as, for example, induced tolerance. Thesecompositions are not inactivated by cellular enzymes or cleared fromcells and organs prior to having the desired effect. Further, long-termtherapy, typically required for the amelioration of many blooddisorders, can be successfully performed. Consequently, doses necessaryfor maintaining a constant effect for the patient are steady andmaterial costs and inconveniences associated with administration aresubstantially reduced.

The mechanism of action of many of the chemical compounds or activeingredients of compositions for the treatment of cystic fibrosisinvolves effecting one or more of the processes of gene transcription,protein translation or processing or transport or stability, cellproliferation, cell recruitment, cell differentiation, or CFTRexpression or activity. Gene expression can be increased or decreased byaltering chromatin and/or nucleosome structure to render a geneticelement more or less susceptible to transcription, by altering DNAstructure, for example, by methylation of G residues, by affecting theactivity of cell-specific transcription or translation factors such asactivators or repressors, or by increasing the rate of transcription ortranslation. CFTR expression can be increased or decreased by affectinggene expression, peptide expression, CFTR assembly, CFTR glycosylationor transport through the Golgi apparatus or the stability of the CFTRmolecule. Cell proliferation may be increased, for example, bystimulating stem cells, pulmonary or pancreatic or other secretory cellgrowth, or decreased, for example, by effecting a cell's period in orability to transverse a stage (S, G2, G 1, M) of the cell cycle. Cellrecruitment may be promoted through the expression of specific cytokinessuch as cell surface receptors or secreted factors. CFTR function may beincreased by promoting chloride transport or other activities of theprotein.

Chemical agents that can be administered as pharmaceutical compositionsinclude phenoxyacetic acid, methoxyacetic acid, butyric acid ethylester, cinnamic acid, hydrocinnamic acid, alpha-methyl cinnamic acid andalpha-methylhydrocinnamic acid (alpha-MHCA) which stimulate alterationsin binding or removal of transcription factors from the proximalpromoter region of certain genes or gene clusters and thereby increasesuppressed gene expression, or serve a chaperones to facilitateprocessing, transport and the thermal or physical stability of mutatedor normal CFTR proteins.

These compositions preferably increase the expression of CFTR, increasethe expression of CFTR genes, increase the number of CFTR-expressingcells or increase the activity of CFTR. Preferably, compositions alsoincrease CFTR expression or function greater than about 30%, morepreferably greater than about 100%, and even more preferably greaterthan about 200%. CFTR intracellular and cell surface expression, geneexpression and cell proliferation can be assayed by measuring foldincreases in expressed amounts of specific mRNA, protein or numbers ofCFTR-expressing cells in treated samples as compared untreated controls.Utilizing this criteria, compositions preferably increase the amount ofCFTR cell surface expression, the amount of CFTR gene expression, thenumber of CFTR-expressing cells by greater than or equal to about1½-fold, preferably about two-fold and more preferably about four-fold.CFTR function can be measured by analysis of chloride iontransport/efflux (cAMP-stimulated or otherwise), patch clamping, sweattesting, or improvement in the symptoms of cystic fibrosis.

One embodiment of the invention is directed to pharmaceuticalcompositions comprising one or more novel chemical agents. Agentsinclude chemicals of the structure R₁—R₂—R₃ or, preferably,R₁—C(O)—R₂—R₃ wherein R₁ is CH_(x), CO, H_(x), NH_(x), OH_(x), SH_(x),COH_(x), CONH_(x), COOH or COSH_(x); R₂ is CH_(x) or a branched orlinear alkyl chain; R₃ is CONH_(x), COSH_(x), COOH, COOR₄, COR₄, CO orOR₄; R₄ is CH_(x), CO, H_(x), NH_(x), OH_(x), SH_(x) or a branched orlinear alkyl chain; phenyl-R₅—R₆—R₇ wherein phenyl is a six carbonbenzyl ring or a hydrogenated, hydroxylated or halogenated six carbonring; R₅ is CH_(x), CO, NH_(x), OH_(x) or SH_(x): R₆ is CH_(x), CO,H_(x), NH_(x), OH_(x), SH_(x) or a branched or linear alkyl chain; R₇ isCH_(x), H_(x), NH_(x), OH_(x), SH_(x), CO, CONH_(x), COOH, COSH_(x),COOR₈, COR₈ or OR₈; R₈ is CH_(x), CO, H_(x), NH_(x), OH_(x), SH_(x) or abranched or linear aryl chain; and phenyl-R₉—R₁₀ wherein R₉ is CH_(x),CO, NH_(x), OH_(x), SH_(x), or a branched or linear aryl chain; R₁₀ isCH_(x), CO, H_(x), NH_(x), OH_(x), SH_(x), CONH_(x), COOH, COSH_(x),COOR₁₁, COR₁₁, CO or OR₁₁; and R₁₁ is CH_(x), CO, H_(x), NH_(x), OH_(x),SH_(x) or a branched or linear alkyl chain; wherein x is 0, 1, 2 or 3.Preferably, R₄ comprises between 1 to 8 carbon atoms and more preferably1, 2, 3 or 4 carbon atoms. Preferably, R₆ comprises between 1 to 8carbon atoms and more preferably 1, 2, 3 or 4 carbon atoms. Preferably,R₈ comprises between 1 to 8 carbon atoms and more preferably 1, 2, 3 or4 carbon atoms.

Examples of chemical compounds of the structure R₁—R₂—R₃ orR₁—C(O)—R₂-R₃ include acids, amines, monoamides and diamides of butyricacid (H₃C—CH₂—CH₂—COOH), butyric acid ethyl ester (CH₂CH₂CH₂COCH₂CH)₃4,4,4-tri fluorobutyric acid (CF₃CH₂CH₂COOH), 2,2-dimethyl butyric acid(C₂H₅C(CH₃)₂CO₂H), 2,2-diethyl butyric acid, 3,3-dimethyl butyric acid(C₆H₁₂O₂), 3,3-diethyl butyric acid, f umaric acid (HOOCCH═CHCOOH),flumaric acid monomethyl and monoethyl ester, fumaric acid monoamide(C₄H₅O₂N), fumaramide (H₂NCOCCHCONH₂), succinic acid (HOOCCH₂CH₂COOH)(succinamic acid and succinamide), 2,3-dimethyl succinic acid andmethoxy acetic acid (CH₃CH₂OCH₃).

Examples of chemical compounds of the structure phenyl-R₅—R₆—R₇ includeacids, amines and amides of phenoxyacetic acid (C₆H₅OCH₂COOH; C₆H₅OCH₂COONH₃), 2- and 3-thiophenoxy propionic acid (C₆H₅SCH(CH₃)COOH; C₆H₅SCH₂CH₂COOH), 2- and 3-phenoxy propionic acid (C₆H₅OCH(CH₃)COOH;C₆H₅OCH₂ CH₂COOH), 2- and 3-phenyl propionic acid (C₆H₅CH(CH₃)COOH;C₆H₅CH₂CH₂ COOH), 4-chlorophenoxy-2-propionic acid (ClC₆OCH₂CH₂CO₂H),methoxy acetic acid (H₃COCH₂CO₂H), and 2-thiophenoxy acetic acid(C₆H₅SCH₂COOH).

Examples of chemical compounds of the structure phenyl-R₉—R₁₀ includeacids, amines and amides of cinnamic acid (C₆H₅CH═CHCOOH), hydrocinnamicacid, dihydrocinnamic acid (C₆H₅CH₂CH₂COOH), a-methyl hydrocinnamic acidor dihydro cinnamic acid, 2,3-dimethyl hydrocinnamic or dihydrocinnamicacid, phenyl acetate ethyl ester (C₆H₅CH(CH₃)CH₂COCH₂CH₃),2-phenoxypropionic acid (C₆H₅OCH₂CO₂H), phenoxy acetic acid(CH₃CH(OC₆H₅)CO₂H, and 3-phenyl butyric acid (C₆H₃CH(CH₃)CH₂COOH).Additional chemical compounds which may or may not be included in theabove classification scheme include monobutyrin, tributyrin(CH₂(OCOCH₂CH₂CH₃)CH(OCOCH₂CH₂CH₃)CH₂(OCOCH₂CH₂CH₃), ethyl-phenyl aceticacid (CH₃ CH₂C₆H₅CH₂COOH), indol-3-propionic acid, indol-3-butyric acid,1- and 2-methyl cyclopropane carboxylic acid (C₅H₈O₂ and C₆H₈O₂),mercaptoacetic acid (C₂H₄O₂S), N-acetylglycine (C₄H₇O₃N), squaric acid(C₄H₂O₄), 4-trifluorobutanol (C₄H₇OF₃), chloropropionic acid(ClCH₂CH₂CO₂H), 3-trimethyl silyl-1-proposulfonic acid sodium(C₆H₁₅O₃SS), 2-oxopantansane (C₅H₈O₃), isobutyl hydroxyl amine HCl(C₄H₁₂OCl), 2-methyl butanoic acid (C₅H₁₀O₂), o-benzoyl lactate,n-dimethylbutyric acid glycine amide, o-dimethyl butyric acid lactate,and diethyl butyric acid.

Agents are useful in pharmaceutical compositions for the treatment ofcystic fibrosis. Preferred agents in such compositions include, forexample, propionic acid, butyric acid, succinic acid, fumaric acidmonoethyl ester, dimethyl butyric acid, trifluorobutanol (C₄H₇OF₃),chloropropionic acid (ClCH₂CH₂COOH), isopropionic acid, 2-oxypentasane(CH₃CH₂CH₂C(O)COOH), 2,2- or 3,3-dimethyl butyric acid (C₆H₁₂O₂), 2,2-or 3,3-diethyl butyric acid (C₈H₁₆O₂), butyric acid ethyl ester,2-methyl butanoic acid (C₅H₁₀O₂), fumaric acid (C₄H₄O₃) and amides andsalts thereof. Other examples include methoxy acetic acid(H₃C(O)CH₂COOH), dimethyl butyric acid, methoxy propionic acid,N-acetylglycine (H₃CC(O)NCH₂COOH), mercaptoacetic acid (HSCH₂ COOH), 1-or 2-methyl cyclopropane carboxylic acid (C₅H₈O₂), squaric acid(C₄H₂O₄), 2- or 3-phenoxy propionic acid, methoxy butyric acid, phenoxyacetic acid, 4-chloro-2-phenoxy 2-propionic acid, 2- or 3-phenoxybutyric acid, phenyl acetic acid, phenyl propionic acid, 3-phenylbutyric acid, ethyl-phenyl acetic acid, 4-chloro-2-phenoxy-2-propionicacid, n-dimethyl butyric acid glycine amide, o-benzoyl lactic acid,o-dimethyl butyric acid lactate, cinnamic acid, dihydrocinnamic acid(C₆H₅CHCH₃COOH), a-methyl-dihydrocinnamic acid, thiophenoxy acetic acid,and amines, amides and salts of these chemicals.

Useful amines and amides include isobutylhydroxylamine:HCl (C₄H₁₂OCl),fumaric acid monoamide (C₄H₅O₂N), fumaramide (H₂NCOCHCHCONH₂),succinamide and isobutyramide (C₄H₉ON). Salts can be sodium, potassium,calcium, ammonium, lithium or choline such as sodium 3-trimethylsilyl-1-proposulfonic acid (C₆H₁₅O₃SiS:Na). Reagents which may beelectrostatically or covalently bonded with the inducing agent includeamino acids such as arginine (arginine butyrate), glycine, alanine,asparagine, glutamine, histidine or lysine, nucleic acids includingnucleosides or nucleotides, or substituents such as carbohydrates,saccharides, lipids, fatty acids, proteins or protein fragments.Combinations of these salts with the inducing agent can also produceuseful new compounds from the interaction of the combination.

Chemical compounds are preferably optically pure with a specificconformation (plus {+} or minus {−}), absolute configuration (R or S),or relative configuration (D or L). Particular salts such as sodium,potassium, magnesium, calcium, choline, amino acid, ammonium or lithium,or combinations of salts may also be preferred, however, certain saltsmay be more advantageous than others. For example, chemical compositionsthat require high doses may introduce too much of a single salt to thepatient. Sodium is generally an undesirable salt because at high doses,sodium can increase fluid retention resulting in tissue destruction. Insuch instances, lower doses or combinations of different or alternativesalts can be used. For example, compounds of the invention may besubstituted with one or more halogens such as chlorine (Cl), fluorine(F), iodine (I), bromine (Br) or combinations of these halogens. Asknown to those of ordinary skill in the art, halogenation can increasethe polarity, hydrophilicity or lipophilicity or a chemical compoundwhich can be a desirable feature, for example, to transform a chemicalcompound into a composition which is more easily tolerated by thepatient or more readily absorbed by the epithelial lining of thegastrointestinal tract. Such compositions could be orally administeredto patients.

Therapeutically effective chemical compounds may be created by modifyingany of the above chemical compounds so that after introduction into thepatient, these compounds metabolize into active forms, such as the formsabove, which have the desired effect on the patient. Compounds may alsobe created which are metabolized in a timed-release fashion allowing fora minimal number of introductions which are efficacious for longerperiods of time. Combinations of chemical compounds can also produceuseful new compounds from the interaction of the combination. Suchcompounds may also produce a synergistic effect when used in combinationwith other known or other compounds.

Compositions are preferably physiologically stable at therapeuticallyeffective concentrations. Physiological stable compounds are compoundsthat do not break down or otherwise become ineffective upon introductionto a patient prior to having a desired effect. Compounds arestructurally resistant to catabolism, and thus, physiologically stable,or coupled by electrostatic or covalent bonds to specific reagents toincrease physiological stability. Such reagents include ammo acids suchas arginine, glycine, alanine, asparagine, glutamine, histidine orlysine, nucleic acids including nucleosides or nucleotides, orsubstituents such as carbohydrates, saccharides and polysaccharides,lipids, fatty acids, proteins, or protein fragments. Useful couplingpartners include, for example, glycol such as polyethylene glycol,glucose, glycerol, glycerin and other related substances.

Physiological stability can be measured from a number of parameters suchas the half-life of the compound or the half-life of active metabolicproducts derived from the compound. Certain compounds of the inventionhave in vivo half lives of greater than about fifteen minutes,preferably greater than about one hour, more preferably greater thanabout two hours, and even more preferably greater than about four hours,eight hours, twelve hours or longer. Although a compound is stable usingthis criteria, physiological stability cam also be measured by observingthe duration of biological effects on the patient. Clinical symptomswhich are important from the patient's perspective include a reducedfrequency or duration, or elimination of the need for oxygen, inhaledmedicines, or pulmonary therapy. Preferably, a stable compound of theinvention has an in vivo half-life of greater than about 15 minutes, aserum half-life of greater than about 15 minutes, or a biological effectwhich continues for greater than 15 minutes after treatment has beenterminated or the serum level of the compound has decreased by more thanhalf.

Preferably, compositions are also not significantly biotransformed,degraded or excreted by catabolic processes associated with metabolism.Although there may be some biotransformation, degradation or excretion,these functions are not significant if the composition is able to exertits desired effect.

Compositions are also preferably safe at effective dosages. Safecompositions are compositions that are not substantially toxic (e.g.cytotoxic or myelotoxic), or mutagenic at required dosages, do not causeadverse reactions or side effects, and are well-tolerated. Although sideeffects may occur, compositions are substantially safe if the benefitsachieved from their use outweigh disadvantages that may be attributableto side effects. Unwanted side effects include nausea, vomiting, hepaticor renal damage or failure, hypersensitivity, allergic reactions,cardiovascular problems, gastrointestinal disturbances, seizures andother central nervous system difficulties, fever, bleeding orhemorrhaging, serum abnormalities and respiratory difficulties.

Compositions useful for treating disorders preferably do notsubstantially affect the viability of a cell such as a normal mammaliancell, the cell being treated or effected by the chemical compound.Normal cell viability, the viability of an untransformed or uninfectedcell, can be determined from analyzing the effects of the composition onone or more biological processes of the cell. Detrimental interferencewith one or more of these cellular processes becomes significant whenthe process becomes abnormal. Examples of quantitatable and qualifiablebiological processes include the processes of cell division, proteinsynthesis, nucleic acid (DNA or RNA) synthesis, nucleic acid(principally DNA) fragmentation and apoptosis. Others processes includespecific enzyme activities, the activities of the cellulartransportation systems such as the transportation of amino acids bysystem A (neutral), system B (acidic) or system C (basic), and theexpression of a cell surface protein. Each of these parameters is easilydetermined as significantly detrimental, for example, in tissue cultureexperiments, in animal experiments or in clinical studies usingtechniques known to those of ordinary skill in the art. Abnormal celldivision, for example, can be mitosis which occurs too rapidly, as in amalignancy, or unstably, resulting in programmed cell death orapoptosis, detected by increased DNA degradation. The determination ofabnormal cell viability can be made on comparison with untreated controlcells. Compositions preferably increase normal cell viability. Increasedcell viability can be determined by those of ordinary skill in the artusing, for example, DNA fragmentation analysis. A decreased amount offragmentation indicates that cellular viability is boosted.Determinations of increased or decreased viability can also be concludedfrom an analysis of the results of multiple different assays. Wheremultiple tests provide conflicting results, accurate conclusions canstill be drawn by those of ordinary skill based upon the cell type, thecorrectness or correlation of the tests with actual conditions and thetype of composition.

Compositions can be prepared in solution as a dispersion, mixture,liquid, spray, capsule or as a dry solid such as a powder or pill, asappropriate or desired. Solid forms may be processed into tablets orcapsules or mixed or dissolved with a liquid such as water, alcohol,saline or other salt solutions, glycerol, saccharides or polysaccharide,oil or a relatively inert solid or liquid. Liquids, pills, capsules ortablets administered orally may also include flavoring agents toincrease palatability. Additionally, all compositions may furthercomprise agents to increase shelf-life, such as preservatives,anti-oxidants and other components necessary and suitable formanufacture and distribution of the composition. Compositions furthercomprise a pharmaceutically acceptable carrier. Carriers are chemical ormulti-chemical compounds that do not significantly a lter or effect theactive ingredients of the compositions. Examples include water, alcoholssuch as glycerol and polyethylene glycol, glycerin, oils, salts such assodium, potassium, magnesium and ammonium, fatty acids, saccharides orpolysaccharides. Carriers may be single substances or chemical orphysical combinations of these substances.

Another embodiment of the invention is directed to combinations ofcompositions comprising a chemical compound in combination with an agentknown to positively affect expression of the CFTR molecule. The agentmay be a chemical compound such as glycerol, acetic acid, butyric acid,D- or L-amino-n-butyric acid, alpha- or beta-amino-n-butyric acid,arginine butyrate or isobutyramide, all disclosed in U.S. Pat. Nos.4,822,821 and 5,025,029. Others include butyrin, 4-phenyl butyrate(C₆H₅CH₂CH₂CH₂COOH), phenylacetate (C₆H₅CH₂COOH), phenoxy acetic acid,all of which and more are disclosed in U.S. Pat. No. 4,704,402, and U.S.patent application Ser. No. 08/398,588 (entitled “Compositions for theTreatment of Blood Disorders” filed Mar. 3, 1995), and derivatives,salts and combination of these agents. The agent may be a protein suchas hsp70 or a growth factor or cytokine. The agent may be a gene or anucleotide sequence. Such composition may have additive or synergisticeffects.

In another embodiment, compositions of the invention may contain one ormore chemical compounds that increase the extent or magnitude of CFTRfunction, increase the expression of the CFTR molecule, increasetransport of the CFTR molecule to the cell surface, increase thehalf-life (physical stability or thermal stability) of the molecule,increase expression from the CFTR gene, increase CFTR transcript levels,or increase post-transcriptional processes which increase the levels ofCFTR transcript, or increase translation or enhance post-translationalprocessing of the CFTR gene product. Stimulation of specific geneexpression involves activation of transcription or translation promotersor enhancers, or alteration of the methylation patterns or histonedistribution along the gene to promote expression. Expression may alsobe stimulated by inhibition of specific transcriptional or translationalrepressors, activation of specific transcriptional or translationalactivation factors, or activation of receptors on the surface ofparticular populations of cells. Stimulation may recruit additionalepithelial cells to the airways, reprogram differentiated epithelialcells to express CFTR. Stimulation may also activate a previouslydormant or relatively inactive gene.

Compositions of the invention may be administered by oral, parenteral,sublingual, rectal or enteral administration, or pulmonary absorption ortopical application. Compositions cam be directly or indirectlyadministered to the patient. Indirect administration is performed, forexample, by administering the composition to cells ex vivo andsubsequently introducing the treated cells to the patient. The cells maybe obtained from the patient to be treated or from a genetically relatedor unrelated patient. Related patients offer some advantage by loweringthe immunogenic response to the cells to be introduced. For example,using techniques of antigen matching, immunologically compatible donorscan be identified and utilized.

Direct administration of a composition may be by oral, parenteral,sublingual, rectal such as suppository or enteral administration, or bypulmonary absorption or topical application. Parenteral administrationmay be by intravenous injection, subcutaneous injection, intramuscularinjection, intra-arterial injection, intrathecal injection,intraperitoneal injection or direct injection or other administration tothe desired site. Injectable forms of administration are sometimespreferred for maximal effect. When long term administration by injectionis necessary medi-ports, in-dwelling catheters, or automatic pumpingmechanisms are also preferred wherein direct and immediate access isprovided to the arteries in and around the heart and other major organsand organ systems.

An effective method of administration to a specific site may be bytransdermal transfusion such as with a transdermal patch, by directcontact to the cells or tissue, if accessible, such as a skin tumor, orby administration to an internal site through an incisions or some otherartificial opening into the body. Compositions may also be administeredto the nasal passages as a spray. Diseases localized to the head andbrain area are treatable in this fashion as arteries of the nasal areaprovide a rapid and efficient access to the upper areas of the head.Sprays also provide immediate access to the pulmonary system and are thepreferable methods for administering compositions to these areas. Accessto the gastrointestinal tract is gained using oral, enema, or injectableforms of administration. Compositions may be administered as a bolusinjection or spray, or administered sequentially over time(episodically) such as every two, four, six or eight hours, every day(QD) or every other day (QOD), or over longer periods of time such asweeks to months.

Orally active compositions are preferred, as oral administration isusually the safest, most convenient and economical mode of drugdelivery. Oral administration is usually disadvantageous becausecompositions are poorly absorbed through the gastrointestinal lining.Compounds which are poorly absorbed tend to be highly polar.Consequently, compounds which are effective, as described herein, may bemade orally bioavailable by reducing or eliminating their polarity. Thiscan often be accomplished by formulating a composition with acomplimentary reagent which neutralizes its polarity, or modifying thecompound with a neutralizing chemical group. Oral bioavailability isalso a problem because drugs are exposed to the extremes of gastric pHand gastric enzymes. These problems can be overcome in a similar matterby modifying the molecular structure to be able to withstand very low pHconditions and resist the enzymes of the gastric mucosa such as byneutralizing an ionic group, by covalently bonding an ionic interaction,or by stabilizing or removing a disulfide bond or other relativelylabile bond.

Compounds may also be used in combination with other agents to maximizethe effect of the compositions in an additive or synergistic manner.Cytokines which may be effective in combination with the compositions ofthe invention include growth factors such as B cell growth factor(BCGF), fibroblast-derived growth factor (FGF), granulocyte/macrophagecolony stimulating factor (GM-CSF), granulocyte colony stimulatingfactor (G-CSF), macrophage colony stimulating factor (M-CSF), epidermalgrowth factor (EGF), vascular endothelial growth factor (VEGF), plateletderived growth factor (PDGF) nerve growth factor (NGF), stem cell factor(SCF), and transforming growth factor (TGF). These growth factors plus acomposition may further stimulate cellular differentiation and/or theexpression of the CFTR molecule or function.

Alternatively, other cytokines and related antigens in combination witha composition may also be useful to treat cystic fibrosis. Potentiallyuseful cytokines include tumor necrosis factor (TNF), the interleukinsIL-1, IL-2, IL-3, IL-4, IL-5, IL-6, etc., recombinant IL receptors,growth factors, colony stimulating factors, erythropoietin (EPO), theinterferon (IFN) proteins IFN-alpha, IFN-beta, and IFN-gamma; cyclic AMPincluding dibutyryl cyclic AMP, hemin, DMSO, hydroxyurea, hypoxanthine,glucocorticoid hormones and cytosine arabinoside. Therapies usingcombinations of these agents would be safe and effective therapiescystic fibrosis. Combinations of therapies may also be effective ininducing improvement of the symptoms of cystic fibrosis such ascompositions of the invention plus the reintroduction of a normal oraltered CFTR gene (gene therapy), toxin or drug conjugated antibodytherapy using monoclonal or polyclonal antibodies directed against thepulmonary cells, or specific anti-sense therapy. Effects may beadditive, logarithmic or synergistic, and methods involving combinationsof therapies may be simultaneous protocols, intermittent protocols orprotocols which are empirically determined.

Another embodiment of the invention is directed to the pulsedadministration of pharmaceutical compositions for the treatment orprevention of cystic fibrosis. Pulsed administration is surprisinglymore effective than continuous treatment as pulsed doses are often lowerthan would be expected from continuous administration of the samecomposition. Each pulse dose can be reduced and the total amount of drugadministered over the course of treatment to the patient is minimized.

In traditional forms of therapy, repeated administration is designed tomaintain a desired level of an active ingredient in the body. Veryoften, complications that develop can be attributed to dosage levelsthat, to be effective, are near toxic or otherwise harmful to normalcells. In contrast, with pulse therapy, in vivo levels of drug dropbelow that level required for effective continuous treatment. Therefore,pulsing is not simply the administration of a sufficiently large bolussuch that there will be therapeutically sufficient drug available for along period of time. Pulsed administration can substantially reduce theamount of the composition administered to the patient per dose or pertotal treatment regimen with an increased effectiveness. This representsa significant saving in time, effort and expense and, more importantly,a lower effective dose substantially lessens the number and severity ofcomplications that may be experienced by the patients. As such, pulsingis surprisingly more effective than continuous administration of thesame composition.

Preferably, compositions contain chemicals that are substantiallynon-toxic. Substantially non-toxic means that the composition, althoughpossibly possessing some degree of toxicity, is not harmful to thelong-term health of the patient. Although the active component of thecomposition may not be toxic at required levels, there may also beproblems associated with administering the necessary volume or amount ofthe final form of the composition to the patient. For example, if thecomposition contains a salt, although the active ingredient may be at aconcentration that is safe and effective, there can be a harmfulbuild-up of sodium, potassium or another ion. With a reduced requirementfor the composition or at least the active component of thatcomposition, the likelihood of such problems can be reduced or eveneliminated. Consequently, although patients may have minor or short termdetrimental side-effects, the advantages of taking the compositionoutweigh the negative consequences.

Compositions most effective at pulsed administration are typicallynon-toxic or non-cytotoxic chemicals without any substantialproteinaceous active component at the therapeutically effective pulseddose. Preferably, treatment does not stimulate apoptosis in the cellsbeing directly treated or in the otherwise normal cells of the bodywhich will also be exposed to the composition.

Individual pulses can be delivered to the patient continuously over aperiod of several hours, such as about 2, 4, 6, 8, 10, 12, 14 or 16hours, or several days, such as 2, 3, 4, 5, 6, or 7 days, preferablyfrom about 1 hour to about 24 hours and more preferably from about 3hours to about 9 hours. Alternatively, periodic doses can beadministered in a single bolus or a small number of injections of thecomposition over a short period of time, typically less than 1 or 2hours. For example, arginine butyrate has been administered over aperiod of 4 days with infusions for about 8 hours per day or overnight,followed by a period of 7 days of no treatment. The interval betweenpulses or the interval of no delivery is greater than 24 hours andpreferably greater than 48 hours, and can be for even longer such as for3, 4, 5, 6, 7, 8, 9 or 10 days, two, three or four weeks or even longer.As the results achieved may be surprising, the interval between pulses,when necessary, can be determined by one of ordinary skill in the art.Often, the interval between pulses can be calculated by administeringanother dose of the composition when the composition or the activecomponent of the composition is no longer detectable in the patientprior to delivery of the next pulse. Intervals can also be calculatedfrom the in vivo half-life of the composition. Intervals may becalculated as greater than the in vivo half-life, or 2, 3, 4, 5 and even10 times greater the composition half-life. For compositions with fairlyrapid half lives such as arginine butyrate with a half-life of 15minutes, intervals may be 25, 50, 100, 150, 200, 250 300 and even 500times the half life of the chemical composition.

The number of pulses in a single therapeutic regimen may be as little astwo, but is typically from about 5 to 10, 10 to 20, 15 to 30 or more. Infact, patients can receive drugs for life according to the methods ofthis invention without the problems and inconveniences associated withcurrent therapies. Compositions can be administered by most any means,but are preferably delivered to the patient as an injection (e.g.intravenous, subcutaneous, intraarterial), infusion or instillation, andmore preferably by oral ingestion. Various methods and apparatus forpulsing compositions by infusion or other forms of delivery to thepatient are disclosed in U.S. Pat. Nos. 4,747,825; 4,723,958; 4,948,592;4,965,251 and 5,403,590.

Compositions administered in pulses have the surprising benefit ofreducing the overall load of drug on the patient as the total amount ofdrug administered can be substantially less than that amount that hasbeen therapeutically administered by conventional continuous therapy.Substantially means that there is more than an insignificant differencebetween the amount or concentration of a composition administered bypulsing according to the invention verses the amount or concentrationadministered using conventional therapy, without compromising thebeneficial effect achieved to the patient. For example, argininebutyrate has been shown to be effective at continuous administration atabout 2000 mg/kg patient weight. Doses of between about 400 to 1500mg/kg, preferably from about 600 to 1000 mg/kg and more preferably from700 to 800 mg/kg, when administered in pulses, are surprisingly morebeneficial as measured by a rise in fetal hemoglobin levels inthalassemic patients. Typical pulsed amounts of arginine butyrate arefrom about 2 to about 20 g/kg/month, and preferably from about 3 toabout 10 g/kg/month wherein the patient receives a total of less thanabout 20 kg per month, preferably less than about 15 kg per month andmore preferably less than about 10 kg per month. The amountsadministered per pulse as well as the total amount of the compositionreceived by the patient over the regimen is substantially reduced.Preferably, the therapeutically effective pulsed dose is less than thecontinuous dose, or less than one half, one third, one quarter, onefifth, one tenth or even one twentieth of the therapeutic continuousdose of the same composition or even less.

Other embodiments and uses of the invention will be apparent to thoseskilled in the art from consideration of the specification and practiceof the invention disclosed herein. All U.S. patents and patentapplications, including provisional applications, and all otherdocuments referenced herein, for whatever reason, are specificallyincorporated by reference. It is intended that the specification andexamples be considered exemplary only, with the true scope and spirit ofthe invention being indicated by the following claims.

1. A method for the treatment or prevention of cystic fibrosiscomprising the administration of a composition comprising aphysiologically-effective amount of one or more agents selected from thegroup consisting of butyric acid ethyl ester, 2,2-dimethyl butyric acid,2,2-diethyl butyric acid, 3,3-dimethyl butyric acid, 3,3-diethyl butyricacid, 2,3-dimethyl succinic acid, methoxy acetic acid, phenoxyaceticacid, 2- and 3-thiophenoxy propionic acid, 2- and 3-phenoxy propionicacid, 2- and 3-phenyl propionic acid, 4-chlorophenoxy-2-propionic acid,methoxy acetic acid, or 2-thiophenoxy acetic acid, or a chemicalcompound of the structure phenyl-R₉—R₁₀ wherein R₉ is CH_(x), CO,NH_(x), OX_(x), SH_(x), or a branched or linear aryl chain; R₁₀ isCH_(x), CO, H_(x), NH_(x), OH_(x), SH_(x), CONH_(x), COOH, COSH_(x),COOR_(x), COR_(x), CO or OR₁₁; and R₁₁ is CH_(x), CO, H_(x), NH_(x),OH_(x), SH_(x) or a branched or linear alkyl chain; wherein x is 0, 1, 2or
 3. 2. The method of claim 1 wherein the chemical compound of thestructure phenyl-R9-R10 is selected from the group consisting of acids,amines and amides of cinnamic acid, hydrocinnamic acid, dihydrocinnamicacid, a-methyl hydrocinnamic acid, dihydro cinnamic acid, 2,3-dimethylhydrocinnamic, dihydrocinnamic acid, phenyl acetate ethyl ester,2-phenoxypropionic acid, phenoxy acetic acid, or 3-phenyl butyric acid.3. The method of claim 1 wherein the one or more agents is substitutedwith one or more halogens.
 4. The method of claim 3 wherein the halogenis selected from the group consisting of chlorine, fluorine, iodine,bromine or mixtures or combinations thereof.
 5. The method of claim 1wherein administration is pulsed administration or timed-releaseadministration.
 6. The method of claim 5 wherein the pulsedadministration comprises a plurality of individual pulses delivered to apatient continuously over a period of 2 hours, 4 hours, 6 hours, 8hours, 10 hours, 12 hours, 14 hours 16 hours, 2 days, 3 days, 4 days, 5days, 6 days, 7 days, two weeks, three weeks or four weeks.
 7. Themethod of claim 5 wherein the pulsed administration comprises aplurality of individual pulses delivered at regular intervals measuringfrom between 3 to 9 hours.
 8. The method of claim 1 wherein thecomposition further comprises a pharmaceutically acceptable carrier. 9.The method of claim 1 wherein the composition further comprises acompound that positively affects expression of a CFTR molecule.
 10. Themethod of claim 9 wherein the compound that positively affectsexpression of the CFTR increases the extent or magnitude of CFTRfunction, increases the expression of the CFTR molecule, increasestransport of the CFTR molecule to the cell surface, increases half-lifeof the CFTR molecule, increases expression from a CFTR gene, increasesCFTR transcript levels, increases post-transcriptional processes whichincreases CFTR transcript levels in the cell, or increases translationpost-translational processing of a CFTR gene product.
 11. The method ofclaim 1 wherein the agent treats defective chloride ion transport.
 12. Amethod for the therapy of cystic fibrosis comprising administering to apatient a quantity of an agent, or pharmaceutically acceptablederivatives thereof, effective for said therapy, said agent selectedfrom the group consisting of butyric acid ethyl ester, 2,2-dimethylbutyric acid, 2,2-diethyl butyric acid, 3,3-dimethyl butyric acid,3,3-diethyl butyric acid, 2,3-dimethyl succinic acid, methoxy aceticacid, phenoxyacetic acid, 2- and 3-thiophenoxy propionic acid, 2- and3-phenoxy propionic acid, 2- and 3-phenyl propionic acid,4-chlorophenoxy-2-propionic acid, methoxy acetic acid, 2-thiophenoxyacetic acid, or a chemical compound f the structure phenyl-R₉—R₁₀wherein R₉ is CH_(x), CO, NH_(x), OH_(x), SH_(x), or a branched orlinear aryl chain; R₁₀ is CH_(x), CO, H_(x), NH_(x), OH_(x), SH_(x),CONH_(x), COOH, COSH_(x), COOR₁₁, COR₁₁, CO or OR₁₁; and R₁₁ is CH_(x),CO, H_(x), NH_(x), OH_(x), SH_(x) or a branched or linear alkyl chain;wherein x is 0, 1, 2 or
 3. 13. The method of claim 12 wherein thechemical compound of the structure phenyl-R9-R10 is selected from thegroup consisting of acids, amines and amides of cinnamic acid,hydrocinnamic acid, dihydriocinnamic acid, a-methyl hydrocinnamic acid,dihydro cinnamic acid, 2,3-dimethyl hydrocinnamic, dihydrocinnamic acid,phenyl acetate ethyl ester, 2-phenoxypropionic acid, phenoxy aceticacid, and 3-phenyl butyric acid.
 14. A method for enhancing expressionof CFTR comprising the administration of a physiologically effectiveamount of one or more agents or pharmaceutically acceptable derivativesthereof, said agents selected from the group consisting of butyric acidethyl ester, 2,2-dimethyl butyric acid, 2,2-diethyl butyric acid,3,3-dimethyl butyric acid, 3,3-diethyl butyric acid, 2,3-dimethylsuccinic acid, methoxy acetic acid, phenoxyacetic acid, 2- and3-thiophenoxy propionic acid, 2- and 3-phenoxy propionic acid, 2- and3-phenyl propionic acid, 4-chlorophenoxy-2-propionic acid, methoxyacetic acid, 2-thiophenoxy acetic acid, and chemical compounds of thestructure phenyl-R₉—R₁₀ wherein R₉ is CH_(x), CO, NH_(x), OH_(x),SH_(x), or a branched or linear aryl chain; R₁₀ is CH_(x), CO, H_(x),NH_(x), OH_(x), SH_(x)CONH_(x), COOH, COSH_(x), COOR₁₁, COR₁₁, CO orOR₁₁; and R₁₁ is CH_(x), CO, H_(x), NH_(x), OH_(x), SH_(x) or a branchedor linear alkyl chain; wherein x is 0, 1, 2 or
 3. 15. The method ofclaim 14 wherein the chemical compounds of the structure phenyl-R₉—R₁₀are selected from the group consisting of acids, amines and amides ofcinnamic acid, hydrocynnamic acid, dihydrocinnamic acid, a-methylhydrocinnamic acid, dihydro cinnamic acid, 2,3-dimethyl hydrocinnamic,dihydrocinnamic acid, phenyl acetate ethyl ester, 2-phenoxypropionicacid, phenoxy acetic acid, and 3-phenyl butyric acid.
 16. The method ofclaim 14 wherein administration is pulsed administration.
 17. The methodof claim 14 wherein enhancement of the expression of CFTR comprisesincreasing the expression of CFTR genes, increasing the number ofCFTR-expressing cells or increasing the function or activity of CFTR.18. The method of claim 14 wherein CFTR expression is enhanced greaterthan about 30%.
 19. The method of claim 14 wherein CFTR expression isenhanced greater than about 100%.
 20. The method of claim 14 whereinCFTR expression is enhanced greater than about 200%.